Circumcision in Turkey

Circumcision is the surgical removal of the prepuce covering the tip of the penis in boys, and it is a practice with both medical and cultural aspects. When performed under appropriate conditions, it provides benefits in terms of hygiene, reducing the risk of infection, and preventing certain diseases.

The subject of how circumcision is performed and which methods are used is handled safely with modern surgical techniques. Sterilization is of great importance in the procedure performed under local or general anesthesia. Laser, clamp, and classical surgical methods are commonly preferred.

Scientific data are taken into consideration when evaluating the benefits and possible risks of circumcision. There are advantages such as a reduction in urinary tract infections and providing partial protection against some sexually transmitted diseases. However, if appropriate care is not provided, there may be a risk of infection and bleeding.

The post-circumcision care process and recovery period are critically important in terms of preventing complications. The area must be kept clean, dressings must be done in accordance with the doctor’s recommendations, and trauma must be avoided. The recovery process is generally short, and the patient returns to normal life in a short time.

What is the foreskin anatomically and which structure is altered by circumcision?

Although the prepuce, which is a very special part of penile anatomy, appears from the outside to be just a layer of skin, it is actually a two-layered, mobile, and protective structure whose inner surface is covered with mucosa and outer surface with normal skin tissue. In almost all newborn male babies, this skin is naturally adhered to the underlying glans penis at birth. As time passes, as part of the body’s normal functioning, epithelial cells shed and a natural secretion called “smegma” accumulates.

Smegma, which is often perceived by parents in society as inflammation or infection, is a completely physiological secretion that accumulates under the foreskin in the form of small white or pale yellow clumps. The main function of this secretion is to allow the skin to slowly and naturally separate from the glans penis. However, this closed and moist area also creates an extremely favorable microenvironment for bacteria to settle and multiply. Especially bacteria found in the intestinal flora and causing urinary tract infections can easily colonize this narrow space. The circumcision procedure permanently facilitates the hygienic management of the area by eliminating this potential bacterial nest and makes the anatomical structure open to the external environment.

What are the medically proven benefits of the circumcision operation for child health?

Medical research over many years and large-scale epidemiological studies clearly reveal the preventive medicine advantages provided by this surgical procedure. Interventions performed especially in early childhood prevent many health problems that may arise in later ages.

The main medical benefits provided by circumcision are as follows:

• Reduction in the risk of urinary tract infection
• Protection against penile cancer
• Decrease in the risk of cervical cancer
• Protection from sexually transmitted diseases
• Permanent treatment of phimosis
• Prevention of paraphimosis
• Prevention of balanoposthitis attacks

One of the most striking of these items is the tremendous decrease in the risk of urinary tract infection. It has been scientifically proven that circumcision in boys, especially in the first year of life, reduces the likelihood of having a urinary tract infection by very significant rates. Considering the potential of febrile urinary tract infections experienced at an early age to leave permanent damage in the kidneys, this protective effect carries vital value.

In the context of cancer protection, the incidence of penile cancer in circumcised individuals is quite low compared to uncircumcised individuals. In addition, this situation directly affects not only the man’s health but also the health of his partner positively. Since removal of the foreskin reduces the risk of carrying and transmitting oncogenic viruses such as Human Papilloma Virus (HPV), the rate of cervical cancer in the female partners of circumcised men also decreases significantly. Similarly, since the risk of transmission of HIV and other sexually transmitted infections through the mucosa is reduced, a major advantage is also provided in terms of general public health. In addition, the only definitive treatment for urgent medical conditions such as phimosis, which is the inability to retract the skin, or paraphimosis, in which the skin strangles the glans penis after being retracted, is the surgical excision of this region.

What is the most appropriate age range for circumcision from a psychological and physical standpoint?

Although it is a procedure that can be performed surgically at any age, some periods stand out clearly when the child’s psychological development and wound healing speed are taken into consideration. In the medical world, certain stages have been defined regarding the timing of this operation based on child psychology.

The developmental stages in childhood are as follows:

• Neonatal period
• Early infancy period
• Play age period
• School age period
• Adolescence period

According to theories of psychological development, the period between ages 2 and 5 (in some sources 6 years) is a very sensitive stage during which children discover their own bodies and genders. Since children’s ability for abstract thinking has not yet fully developed in this age range, they may perceive any surgical intervention to their sexual organs as a punishment or as a major threat to their bodily integrity. This situation carries the potential to cause serious psychological trauma in the future. Therefore, unless there is an absolute medical necessity such as recurrent infections endangering the child’s kidney health, postponing the operation in this age range is the healthiest approach. If it absolutely must be done, it should definitely be performed under deep sleep so that the child does not remember the process in any way.

On the other hand, the neonatal period and the first few months constitute a golden window of opportunity from a surgical perspective. In this period, the rate of cell renewal is at its highest level, wound healing is completed within days, and most importantly, there is no possibility of the baby being psychologically affected or traumatized by this condition. This early period, in which risks such as bleeding and infection are also statistically at their lowest, is the most comfortable and convenient time frame for parents.

How are pain control and anesthesia management ensured during the circumcision operation?

The cornerstone of successful surgery and the comfortable recovery process afterward is correct and effective pain management. The child not feeling pain in any way during the procedure is both a humane necessity and a technical requirement for the surgeon to be able to work precisely. The choice of anesthesia is carefully determined according to the child’s age, weight, and general medical condition without remaining bound to a standard template.

The anesthesia and analgesia methods preferred in modern medicine are as follows:

• Dorsal penile nerve block
• Caudal anesthesia
• Topical anesthetic creams
• Mask anesthesia
• Sedation applications

In newborns and babies in the first months, local anesthesia methods are quite safe and effective. Special anesthetic creams applied to the area some time before the procedure numb the skin surface, thus eliminating even needle insertion pain. Then, complete numbness is achieved by injecting anesthetic substance with very fine-tipped needles into the points where the nerves providing sensation to the penis pass.

However, when the baby begins to move, especially after the sixth month and in childhood, numbing only that region is not sufficient. Keeping the child away from the operating room environment, instrument sounds, and the stress of the environment is essential for psychological health. Therefore, general anesthesia or deep sedation provided by modern pediatric anesthesia drugs is today the safest approach. The child’s sleeping completely throughout the procedure allows the surgeon to work with millimetric precision and without error, while also preventing the child from remembering this process as a bad memory in life. Current pediatric anesthesia drugs are eliminated from the body very quickly and the waking process is extremely comfortable.

What are the main circumcision surgical techniques applied in modern medicine and urology?

Although there is a widespread belief in society that this procedure is performed in a standard and single way, there are many different surgical techniques that can be preferred according to anatomy, age, and tissue structure. Each technique has its own mode of application, advantages, and unique subtleties:

The most frequently applied techniques in clinical practice are as follows:

• Sleeve technique
• Dorsal slit technique
• Bell-type clamps
• Plastic ring device
• Heat knife systems
• Cyanoacrylate tissue adhesives

The sleeve technique, also known as the sleeve procedure, is one of the most refined methods of classical surgery and one that gives the most aesthetic results. In this technique, the measurements of the inner and outer skin are taken meticulously, and the excess tissue is removed as a whole with very precise circular incisions. Bleeding control is achieved by securely ligating the vessels one by one, and the wound edges are closed with very fine aesthetic sutures that dissolve spontaneously in the body over the course of weeks. There is no need for a stressful process such as suture removal, and the cosmetic result is excellent. The dorsal slit technique is generally the opening of the skin from above as a first step in very narrowed (phimosis) tissues in order not to damage the glans penis; however, it is always completed with the sleeve technique for cosmetic integrity.

Metal clamps, which are among the apparatus-based methods, work on the logic of strongly compressing and crushing the tissue to close the blood vessels. The excess skin is then cut with a scalpel and generally requires no sutures. However, there is a very critical medical safety rule here; when metal apparatuses are used, electrocautery devices that generate electric current should definitely not be used to burn tissue. The electric current may spread through the metal to the entire organ and cause irreversible serious burns. In the plastic ring method, a transparent device is placed and tied over with thread; today it is very popular especially in newborns because it is quick and sutureless. The tied tissue naturally dries within a few days and falls off together with the plastic piece.

In children with bleeding disorders, for example hemophilia, heat knife technology is revolutionary. This system cuts tissue using only high heat energy without giving electric current to the body and at the same time seals microscopic vessels, making it possible to work with zero bleeding. Tissue adhesives are a fast alternative for families who do not want suture marks; however, they should be carefully selected on a case-by-case basis in children approaching adolescence because there is a risk of the glued line opening due to nighttime erections.

How should the recovery and home care process be managed after circumcision surgery?

No matter how flawless the surgical technique applied is, half of the final success and an excellent aesthetic outcome are achieved through the correct care process provided at home after the operation. Although the penis returns to its normal function within the first few days, the reduction of tissue edema and full cosmetic healing take a period of two to three weeks.

The basic care steps to be observed at home after the operation are as follows:

• Regular use of pain-relieving syrup
• Application of the prescribed barrier creams
• Bathing with warm and clean soapy water
• Avoiding impact games
• Use of special protective underwear

During the first 24 hours, some swelling, mild redness, and a few pinkish drops staining the diaper or underwear on the surgical incision line are completely normal parts of the process. In these first days, the painkillers containing paracetamol or ibuprofen prescribed for the child’s comfort should be given regularly according to schedule without interruption. Aspirin-derived medications, which have the property of increasing the risk of bleeding, should definitely be avoided.

Contrary to popular belief, taking a bath does not harm the wound; on the contrary, a warm and soapy body bath taken 48 to 72 hours after the operation significantly accelerates tissue healing and reduces the risk of infection by preventing the accumulation of leakage in the wound area. After bathing, the wound area should be gently dried and the antibiotic-containing or cell-renewing creams recommended by the physician should be applied generously. These creams both create a physical shield against microbes and prevent the wound from sticking to the diaper or underwear and bleeding again. In children who walk and play active games, the use of special protective underwear with a plastic dome at the front makes it possible to return to daily life very quickly and safely.

What are the possible complications and risks that may be encountered after circumcision surgery?

Although it is perceived from the outside as a fairly simple procedure, like every intervention not performed in accordance with surgical discipline and tissue anatomy, circumcision also has its own undesirable outcomes and risks. These risks are generally classified as those occurring in the early period and those occurring in the late period.

The complications that may be seen frequently or rarely are as follows:

• Surgical site bleeding
• Wound site infections
• Glans penis injuries
• Narrowing of the urinary opening
• Development of buried penis
• Aesthetic asymmetries
• Insufficient skin removal

Bleeding is the early complication that worries parents the most after the procedure, but it is also the most frequently encountered. Mild oozing-type bleeding usually stops on its own by applying pressure with a sterile gauze pad for a few minutes. However, in spurting or persistent bleeding, medical support should be sought without delay and, if necessary, an additional suture should be placed in that vascular area. Infection usually develops as a result of non-compliance with hygiene rules; it manifests itself with increasing redness, increase in heat, and foul-smelling discharge, and can be treated rapidly with the correct antibiotics. Injuries to the glans penis are a serious medical condition that may occur especially in faulty clamp use and require urgent re-repair.

One of the most common late-period problems is narrowing of the urinary opening. After the protective shield of the foreskin is removed, the ammonia in the urine accumulated in the diaper comes into direct contact with the sensitive urinary opening. This chemical contact irritates the area, and healing tissue may shrink and narrow the urinary opening. The child strains while urinating and begins to urinate in a very thin, thread-like, and forceful stream. The solution is generally the re-widening of that opening with a small intervention under outpatient clinic conditions. Another important problem is the development of buried penis. Especially in overweight children with more fat accumulation in the groin area, the healing skin tissue may trap the penis completely within the abdominal fat. This creates serious hygiene and psychological problems, and in advanced cases may require anatomical corrective operations.

In which anatomical and systemic diseases should circumcision definitely not be performed or should be postponed?

Before every surgical procedure, taking a detailed medical history and performing a physical examination are of vital importance. As a result of this examination, some conditions may be detected in the child’s body or systemic functioning that make circumcision dangerous or impossible.

The medical conditions in which circumcision should definitely not be performed or should be postponed are as follows:

• Hypospadias disease
• Advanced buried penis
• Penile curvatures
• Hemophilia disease
• Bleeding and clotting disorders
• Active local infections

Hypospadias, also known among the public as prophet circumcision, is the anomaly in which the urinary opening is located not at the tip of the penis but further back on the underside. The appearance of these children is as if they are half circumcised. Performing a standard circumcision in this case is a major medical error. Because the skin tissue in that region, which is planned to be cut and removed, is the most valuable spare tissue source to be used for reconstructing the urinary tract properly in the child’s later months; this tissue must definitely be preserved.

Likewise, if there is a significant anatomical curvature of the penis, the circumcision procedure should be postponed to the appropriate time to be performed simultaneously with the major cosmetic operation that will correct this curvature. In children with deficiencies of clotting factors in the blood, such as hemophilia, even an ordinary incision leads to unstoppable, life-threatening bleeding. In these children, detailed blood tests should be performed before the procedure, the missing clotting proteins should be supplemented intravenously, and surgery should never be started until all blood values are brought to completely normal levels.

According to legal regulations, who is authorized to perform circumcision operations and what are their responsibilities?

Circumcision, which in past years was often performed by unlicensed persons within the traditional dynamics of society, is today a medical procedure framed by strict boundaries through laws and medical regulations. The legal legislation in Turkey states very clearly who may perform this irreversible intervention on bodily integrity.

Pursuant to Law No. 1219 in our country, circumcision is accepted as a bloody surgical intervention and can legally only be performed by physicians holding a medical degree. It is strictly forbidden for non-physician traditional practitioners, health technicians, or other professional groups to perform this procedure, and it is subject to severe penal sanctions and prison sentences. In the name of medical quality, anatomical mastery, and the ability to manage a possible complication instantly, the ideal approach is for the procedure to be performed by urology specialists or pediatric surgery specialists who are proficient in surgical discipline, in operating rooms or fully equipped clinic environments offering fully sterile conditions.

If a child suffers permanent damage or loss of function as a result of careless procedures performed contrary to medical rules, sterilization standards, or appropriate technique, this situation is evaluated within the scope of medical malpractice. In legal processes, the competence of the person performing the procedure, the precautions taken, and the medical care shown are examined extremely meticulously.